Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | P000562 | AR |
NPI | 1003153750 |
---|---|
Provider Name | Mr. Mark M Kelley |
First Address | Little Rock, AR 72210-5509 |
Second Address | Elkridge, MD 21075-6115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2013 |
Last Update Date | 14/01/2013 |